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Event Notification Report for August 27, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/26/2015 - 08/27/2015

** EVENT NUMBERS **


51327 51328 51330 51341 51345 51347 51348 51349 51351

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Agreement State Event Number: 51327
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: UNKNOWN
Region: 1
City: JERSEY CITY State: NJ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES McCOLLOUGH
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/18/2015
Notification Time: 12:15 [ET]
Event Date: 08/15/2015
Event Time: [EDT]
Last Update Date: 08/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - ORPHAN SOURCE FOUND IN A GARBAGE TRUCK

"A garbage truck containing a radioactive source was reported by local police in Union City, NJ. NJ State police preliminarily identified Ra-226, which was confirmed by NJDEP Radiation Program staff who responded to the event. Exposure rate was measured as 60 mR/hr on contact on the truck. Based on measurements, activity was estimated to be 10 mCi. The US DOT was contacted, and approved issuance of a DOT Special Permit 11406 even though readings exceeded 50 mR/hr. Truck was moved to truck owner's (Galaxy Sanitation) location in Jersey City, NJ., where the hired contractor sorted the load and found a small radium source. No identifying information was on the source. It has been adequately shielded and secured at the site pending disposal.

"NJDEP will continue to monitor the situation and provide updates as necessary."

The garbage truck made a pickup in Union City, New Jersey and was stopped by the police because the truck was leaking liquid. As the officer approached the truck, his paging radiac alarmed.

New Jersey Incident: C569188

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Agreement State Event Number: 51328
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: STERIGENICS INTERNATIONAL, INC.
Region: 4
City: HAYWARD State: CA
County:
License #: 6268-01
Agreement: Y
Docket:
NRC Notified By: NIKA HEWADIKARAM
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/18/2015
Notification Time: 17:52 [ET]
Event Date: 07/21/2015
Event Time: 00:11 [PDT]
Last Update Date: 08/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - IRRADIATOR SOURCE RACKS FAILED SAFE

The following report was received via e-mail:

" On 07/21/15, Sterigenics Corporate RSO [Radiation Safety Officer] contacted RHB-Sacramento office [California Radiation Health Branch] via an email and telephone to report the following event in accordance with 36.83(a)(4). His email stated the following:

"Last night [7/21/15] at approximately 12:11 AM PDT at the Sterigenics Hayward Facility (Radioactive materials License 6268-1), the pneumatic cylinder used to raise one of the two source racks (Hoist #1) failed to function as designed. The failure did NOT cause a 'stuck source' nor was there any risk of exposure to any individual as a result of this failure. The source did return to the 'down' position in the pool as designed, however, the pneumatic cylinder experienced a failure and a broken flange and is not operable.

"We [Sterigenics} will review in detail the cause of this failure and implement appropriate corrective action including any necessary changes in maintenance and equipment and report these changes to you [California] in writing within 30 days as required by 10CFR36.83 (b).

"In the interim, the facility will not commence operations until repairs are completed to the hoist and approval to commence operations is granted by the Corporate RSO and Corporate Engineering.

"[Sterigenics] further stated that there is no emergency or current issue. A corporate engineer will arrive in San Francisco by 2:00 on 7/21/15 to work on the irradiator. Facility is staffed 24/7 and will notify RHB before resuming any operations.

"[California] RHB will be following up with the licensee."

California Event 072115

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Non-Agreement State Event Number: 51330
Rep Org: ELEKTA, INC.
Licensee: ELEKTA, INC.
Region: 1
City: ATLANTA State: GA
County:
License #: 10-35096-01
Agreement: Y
Docket:
NRC Notified By: DEBRA BENSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/19/2015
Notification Time: 09:48 [ET]
Event Date: 08/18/2015
Event Time: 10:18 [EDT]
Last Update Date: 08/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
KENNETH RIEMER (R3DO)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

FLEXITRON SOURCE LODGED IN CHECK RULER

"On the morning of August 18, 2015, the Elekta Field Service Engineer (FSE) was called to the [Customer's facility, McLaren Cancer Institute Macomb, in Mt. Clemens, MI] to investigate an obstruction error involving a 10.2 Ci Ir-192 source and a Flexitron HDR. The facility was using a microSelectron source position check ruler to check the source positioning of the Flexitron source. The source became lodged in the check ruler. The system E-stop was unable to retract the source.

"The FSE placed the check ruler and stuck source assembly into the customer's microSelectron HDR (mHDR) Emergency Service container (ESC) in order to secure the radioactive material in a shielded container. He then tried to manually retract the source back into the Flexitron unit which was also unsuccessful.

"Elekta RSO [Radiation Safety Officer] and FSE engaged the assistance from Senior Technical Support in Veenendaal [Netherlands]. After several troubleshooting attempts, the final decision was to remove the source tail in its entirety from the Flexitron unit. During the whole process, the source cable, check ruler and transfer tube remained secured in the emergency service container.

"Currently, the customer's mHDR ESC, which contains the source cable assembly, is secured and being bunkered inside the facility's 'dog house.' The survey readings of the ESC obtained by the customer physics staff were 50 mR/hr at the surface hot spot and 18 mR/hr at 1 meter.

"The FSE has checked the mechanical condition of the Flexitron unit and has loaded a dummy source. The unit is functioning properly.

"Elekta has reached out to their source manufacturer for assistance in transporting the source assembly in its entirety out of the facility.

"Elekta has escalated this case to the complaint handling department at Elekta/Nucletron B.V. for investigation. Further information will be forwarded upon receipt."

There were no over exposures or contamination involved with this event.

* * * UPDATE AT 1331 EDT ON 08/19/15 FROM PRAVEEN DALMIA OF MT. CLEMENS REGIONAL MEDICAL CENTER TO JEFF HERRERA * * *

This event was reported by Mt. Clemens Regional Medical Center d/b/a McLaren McComb, Mt. Clemens, MI. NRC License No. 21-04080-01 - See EN # 51341

Notified R1DO (DeFrancisco), R3DO (Riemer) and NMSS Events Notification Group via email.

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Non-Agreement State Event Number: 51341
Rep Org: MCLAREN MCCOMB
Licensee: MCLAREN MCCOMB
Region: 3
City: MT. CLEMENS State: MI
County:
License #: 21-04080-01
Agreement: N
Docket:
NRC Notified By: PRAVEEN DALMIA
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/19/2015
Notification Time: 13:31 [ET]
Event Date: 08/18/2015
Event Time: 10:35 [EDT]
Last Update Date: 08/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

FLEXITRON SOURCE LODGED IN CHECK RULER

On August 18, 2015, at 1035 EDT as a part of acceptance of a new Flexitron mHDR Unit, [Mt. Clemens Regional Medical Center d/b/a McLaren McComb] tested the source position accuracy using a position check ruler. Licensee programmed the source so that it would go to certain positions. The positions were initialized at 1034 EDT. The source was being watched with the room monitor camera and the camera was zoomed in on the position and not the entire ruler. The source was viewed moving out and passing the positions. The source was supposed to dwell two seconds in each position. After 10 seconds, the cable was seen retracting. At 1035 an error message was received from the machine. The camera was zoomed out and noticed the cable was stuck in the ruler and the source was lodged somewhere between the faceplate and the groove in the ruler. At this point the service engineer from Elekta was there and he looked at the situation and the door had been decided to be opened so the source could be retracted to resolve the situation. With the door open, the room monitor was showing radiation present so we closed the door. At this point, the service engineer engaged the emergency switch and tried to add additional force to the source to retract. This was unsuccessful. Contacted the Elekta Radiation Safety Officer (RSO) for advice. The Elekta RSO suggested to go into the room and retract the source manually. The service Engineer and the Director for Radiation Services then entered the room to secure the ruler with the source in it inside the lead pig sitting right next to the mHDR unit. The plan for securing the source and ruler was discussed and approved with the Elekta RSO.

The event was planned and timed. It took 11 seconds from opening the door to securing the source inside the pig. The source cable was secured to the pig. The pig was secured inside a cabinet and the room was secured to prevent unauthorized entry.

The exposure around the container was 50 mR/hr at the surface and 18 mR/hr at one meter away. Lead bricks were placed around the cabinet to reduce the exposure and the dose was measured at <1mR/hr at the lead bricks where the door is located.

The Device is an Elekta Nucletron Flexitron
Serial Number: 00225

Source: Ir-192, 12.21 Ci on 7/30/2015
Serial Number: D363E-0477
Model Number: 136.147

This event was also reported by the device manufacturer, ELEKTA, at 0948 EDT on 08/19/2015 NRC License No. 10-35096-01- SEE EN # 51330

* * * UPDATE PROVIDED BY MARK YUDELEV TO JEFF HERRERA AT 1519 EDT ON 08/24/2015 * * *

The following additional information summary was excerpted from a detailed time line provided by licensee via email:

"McLaren Macomb was in the middle of a project to replace a microSelectron v2 HDR unit with a Flexitron unit. The installation was scheduled to be completed on Friday, August 14, 2015, with training and commissioning to begin immediately. However, the dedicated camera for source position verification was pending shipment and installation by the vendor. In light of this missing camera, a Source Position Ruler was borrowed from our sister facility at Karmanos Cancer Institute in Detroit, MI to check the source position accuracy with Gafchromic film as part of acceptance procedures.

"On August 18, 2015, the source position check ruler was connected to the Flexitron channel five using matching transfer tubes. The plan was created for the source to dwell at positions 360 (most proximal), 370, 380, 390, 395, and 400mm (most distal) within the ruler for two seconds each. In the absence of dedicated Elekta camera, the CCTV camera for in-room patient monitoring was used. The camera was zoomed on the part of the ruler where the source was expected to dwell. The plan was executed successfully with the source position check ruler two times. On the third attempt, the source got wedged inside the ruler and could not be retracted into the HDR safe. No patient was involved in this incidence and the event did not result in any unplanned exposure to any personnel."

"[During source retrieval] , the total time from entering the room until the source was secured inside the emergency container was 11.16 seconds, which would result in total exposure of 140 mRem to the whole body. The survey around the lead container showed an exposure rate of 8 mR/hr at the top, 48 mR/hr at the side and 18 mR/hr 3 feet away. The background radiation recorded by the meter was 0.002 mR/hr. The power to the unit was removed. The radiation survey meter recorded background radiation at the console area and patient access hall about 20 feet away from HDR door.

"The door to the HDR room was secured. The automatic door switch to the HDR room was disabled, and the door knob inside the room turned so that the keypad to unlock the door was deactivated. The electrical door opener was also disengaged from inside the room. As such, one could only enter the room using a dedicated key. There are only two copies of the key which are in the possession of the Authorized Medical Physicists[AMP]. A 'Do Not Enter' sign, along with the AMPs name and mobile phone number, was placed on the door.

"The emergency container was placed inside the HDR cabinet into the back corner and the cabinet locked. The survey meter showed an exposure rate of 5 mR/hr at the cabinet door. A wall was built around the emergency container using 8 inch x 5 inch x 2inch steel bricks. This reduced the exposure rate at the cabinet door to about 1 mR/hr."

Notified R1DO(DeFrancisco), R3DO(Skokowski) and NMSS Events Notification (via email).

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Power Reactor Event Number: 51345
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: SAMANTHA MILOSH
HQ OPS Officer: DAN LIVERMORE
Notification Date: 08/26/2015
Notification Time: 09:45 [ET]
Event Date: 08/26/2015
Event Time: 05:48 [EDT]
Last Update Date: 08/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
PAUL KROHN (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

SPURIOUS INTERMITTENT ACTUATION OF AN EMERGENCY NOTIFICATION SYSTEM SIREN

"At 05:48 [EDT] BVPS [Beaver Valley Power Station] received notification that siren #6, Potter Township Municipal Building, was sounding intermittently. The fire department activation cable to the siren was severed by a motor vehicle. The ENS activation function remains functional.

"This event is reportable as a 4-hour Non-Emergency Notification 10 CFR 50.72(b)(2)(xi) as 'a News Release or Notification of Other Government Agency.'

"The Resident Inspector has been notified."

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Power Reactor Event Number: 51347
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: CURTIS MARTIN
HQ OPS Officer: NESTOR MAKRIS
Notification Date: 08/26/2015
Notification Time: 13:20 [ET]
Event Date: 08/26/2015
Event Time: 08:50 [CDT]
Last Update Date: 08/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
VIVIAN CAMPBELL (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION REGARDING MATERIAL BEING RELEASED AND RECOVERED

"On 8/26/2015, it was determined that a report to the NRC under 10 CFR 50.72(b)(2)(xi) may have been missed. The station is making this report due to the station making a courtesy call to a State agency regarding release of radioactive waste from the site as non-radioactive material.

"The original event involved a release of 14 bags of debris from the Administration Building roof prior to survey results being obtained. The bags were recovered from the local landfill and a determination was made that the amount of material temporarily removed from the Protected Area was below NRC reporting limits per 10 CFR 20.2201 'Reports of theft or loss of licensed material.'

"On 5/29/13 a courtesy phone call was made to the Nebraska Department of Health and Human Services (Radiation Control Program) informing the authority of the event. There were no state notification requirements based on the low level of licensed material released (and then recovered) from the site.

"This is a four hour report made in accordance with 10 CFR 50.72(b)(2)(xi) as 'Any event or situation, related to the health and safety of the public or on-site personnel, or protection of environment, for which a news release is planned or notification to other government agencies has been or will be made.'

"There was no overexposure to a member of the public.

"The NRC Resident and State of Nebraska have been informed."

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Power Reactor Event Number: 51348
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: MARIA ZAMBER
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/26/2015
Notification Time: 15:47 [ET]
Event Date: 08/26/2015
Event Time: 07:40 [CDT]
Last Update Date: 08/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
VIVIAN CAMPBELL (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

BOTH EMERGENCY DIESEL GENERATORS DECLARED INOPERABLE

"This is a non-emergency notification from Waterford 3. On August 26, 2015, at 0111 CDT, Emergency Diesel Generator (EDG) 'A' was declared inoperable following a trip of EDG 'A' on Generator Differential. Technical Specification (TS) 3.8.1.1 actions b. and d. were entered. EDG 'A' was being routinely run in accordance with OP-903-115, 'Train A Integrated Emergency Diesel Generator/Engineering Safety Features Test', Section 7.4, '24 hr EDG A Run with Subsequent Diesel Start' to satisfy Technical Specification Surveillance Requirement 4.8.1.1.2 6. EDG 'B' was subsequently started per TS 3.8.1.1 action b. (1). At 0740 CDT, EDG 'B' was declared inoperable and TS 3.8.1.1 f. was entered due to the exhaust fan not starting when the diesel engine was started.

"Troubleshooting determined that the EDG B exhaust fan did not start due to HVR-501B (EG B ROOM OUTSIDE AIR INTAKE DAMPER) not opening. Action was taken to isolate air and fail HVR-501B to its open safety position. At 1001 CDT, EDG 'B' was declared operable and TS 3.8.1.1.f. was exited following verification of proper operation of the EDG 'B' exhaust fan.

"Waterford 3 is currently in TS 3.8.1.1 actions b. and d. Actions to verify a temporary EDG is available and restore EDG 'A' to operable status are in progress.

"This event is reportable pursuant to 10 CFR 50.72(b)(3)(v) (A) and 10 CFR 50.72 (b)(3)(v) (D), 'event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to (A) shut down the reactor and maintain it in a safe shutdown condition' and (D) 'mitigate the consequences of an accident due to both emergency diesel generators being inoperable.'"

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 51349
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TOM MULHOLLAND
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/26/2015
Notification Time: 16:30 [ET]
Event Date: 08/26/2015
Event Time: 12:15 [EDT]
Last Update Date: 08/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
PAUL KROHN (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION DUE TO APPENDIX R POSTULATED FIRE

"On 8/26/2015 at 1215 [EDT], a review of the Salem Appendix R Safe Shutdown Analysis in response to the Byron Event Notification #51334 and Braidwood Event Notification #51335, identified a fire scenario that could cause spurious operation of the pressurizer power operated relief valves (PORVs) (PR1 and PR2) and also prevent the ability to close the PORV block valves (PR6 and PR7) until AC power is restored to close the block valves. This scenario would result in the loss of reactor coolant system (RCS) inventory and pressure control that is not accounted for in safe shutdown analysis. The above fire scenario is applicable to a fire in the Control Room and Relay Room fire areas.

"Hourly fire watches of the Relay Room have been implemented. In addition, the Control Room is continuously staffed by the Operating Shift. In addition, the Relay Room is equipped with automatic detection and suppression.

"This event is being reported under 10CFR50.72(b)(3)(ii)(B), for 'any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.'"

The NRC Resident Inspector has been notified.

The licensee will be notifying the Lower Alloways Township, the State of New Jersey and the State of Delaware.

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Power Reactor Event Number: 51351
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: WILLIAM MCCOLLUM
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/26/2015
Notification Time: 21:44 [ET]
Event Date: 08/26/2015
Event Time: 19:20 [EDT]
Last Update Date: 08/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
PAUL KROHN (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

TREE BRANCH FELL ON AMTRAK POWER LINE AND CAUSED BRUSH FIRE

"A small brush fire occurred adjacent to an AMTRAK railroad right of way that passes through the Millstone Power Station owner controlled area, due to a downed tree branch that knocked down an AMTRAK electrified power line. The fire is outside the protected area of the site, and poses no public hazard or threat to building or structures. Outside assistance has been requested. Waterford Fire Department and AMTRAK have responded, and have eliminated the source and extinguished the fire. This report is being made pursuant of 10CFR50.72(b)(2)(xi). There is no radioactive release associated with this event. Dominion may respond to public inquiry, but no press release is planned."

The NRC Resident Inspector has been notified.

The Connecticut State Department of Energy and Environmental Protection and Waterford Dispatch were notified.

Page Last Reviewed/Updated Thursday, August 27, 2015
Thursday, August 27, 2015